BILL ANALYSIS

H.B. 3675

By: Paddie

Human Services

Committee Report (Unamended)

BACKGROUND AND PURPOSE

Concerns have been raised that some Medicaid managed care organizations are requiring an optometrist or ophthalmologist to seek prior authorization for nonsurgical eye care services, although Medicaid recipients are entitled to have direct access to these services without any prior authorization. H.B. 3675 seeks to address these concerns by clarifying that a recipient is entitled to receive these services without any requirement that the patient or practitioner obtain a certain referral, prior authorization, or precertification.

CRIMINAL JUSTICE IMPACT

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

H.B. 3675 amends the Government Code to prohibit the Health and Human Services Commission (HHSC) from preventing an applicable eye health provider from enrolling as a Medicaid provider if the provider either joins an established practice of a health care provider or provider group that has a contract with a managed care organization to provide health care services to Medicaid recipients or is employed by or otherwise compensated for providing training at an applicable institution of higher education; applies to be an enrolled provider under the Medicaid program; if applicable, complies with the requirements of the contract between the provider or the provider's group and the applicable managed care organization; and complies with all other applicable requirements related to being a Medicaid provider. The bill establishes that an applicable eye health provider or institution of higher education is an optometrist who is licensed by the Texas Optometry Board, a therapeutic optometrist who is licensed by the Texas Optometry Board, an ophthalmologist who is licensed by the Texas Medical Board, and an institution of higher education that provides an accredited program for training as a Doctor of Optometry or an optometrist residency or training as an ophthalmologist or an ophthalmologist residency. The bill prohibits HHSC from preventing such an institution of higher education from enrolling as a Medicaid provider if the institution has a contract with a managed care organization to provide health care services to Medicaid recipients, applies to be an enrolled provider under the Medicaid program, complies with the requirements of the contract between the provider and the applicable managed care organization, and complies with all other applicable requirements related to being a Medicaid provider.

H.B. 3675 requires HHSC to require, subject to Human Resources Code provisions relating to the prohibition against certain health care service providers being Medicaid providers, each managed care organization that contracts with HHSC under any Medicaid managed care model or arrangement to provide health care services to recipients in a region to include in the organization's provider network each optometrist, therapeutic optometrist, and ophthalmologist that joins an established practice of a health care provider or provider group or is employed at an applicable institution of higher education, in accordance with the bill's provisions, and each applicable institution of higher education in the region who agrees to comply with the terms and conditions of the organization, who agrees to accept the prevailing provider contract rate of the organization, and who agrees to abide by the standards of care required by the organization.

H.B. 3675 amends the Human Resources Code to revise provisions relating to a Medicaid recipient's selection of and access to an ophthalmologist or therapeutic optometrist by removing the required condition for selection that the professional specialty practice for which the practitioner is licensed also be a practice for which the practitioner is credentialed and by specifying that a recipient's entitlement to have direct access to an eligible practitioner applies without any requirement that the patient or practitioner obtain a certain referral, prior authorization, or precertification.

H.B. 3675 requires HHSC, in a contract with a Medicaid managed care organization that is entered into or renewed on or after the bill's effective date, to require that the organization comply with the bill's provisions and requires HHSC to seek to amend each contract entered into with an organization before the bill's effective date to require those organizations to comply with the bill's provisions. The bill establishes that to the extent of a conflict between the bill's provisions and a provision of a contract with an organization entered into before the bill's effective date, the contract provision prevails. The bill prohibits its provisions from being construed as authorizing or requiring implementation of Medicaid managed care delivery models in regions in Texas in which those models are not used on the bill's effective date for the delivery of Medicaid services.

EFFECTIVE DATE

September 1, 2017.